Programs for treating addiction in doctors pose ethical issues

State physician health programs (PHPs) play a key role in helping doctors with substance abuse problems. But the current PHP system is inconsistent and prone to potential conflicts of interest and ethical issues, according to a review available as publish ahead of print content from the December 2012 issue of Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine.

In the article, Drs J. Wesley Boyd and John R. Knight of Harvard Medical School point out "substantial variability in states' PHP policies and practices, often raising serious ethical and managerial questions." Collectively the authors served as PHP associate directors for more than 20 years; based on that experience they write, "We recommend that the broader medical community begin to reassess PHPs as a whole in an objective and thoughtful manner."

'Coercive' Nature of PHP System Raises Ethical and Managerial Issues

Most states currently have PHPs, which help physicians with substance abuse disorders. State PHPs meet with, assess, and monitor doctors referred for substance abuse or other mental and behavioral health problems. hey also make provisions for follow-up and monitoring of treated physicians, including random drug testing.

The PHP system achieves good results in treating substance abuse disorders in physicians, with much higher success than reported for other groups of patients. However, Drs Boyd and Knight identify several ethical concerns related to the "coercive" nature of the system. They write, "Once a PHP recommends monitoring, physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine."

One issue is the high cost of evaluation and treatment. Insurance sometimes does not reimburse physicians for evaluations recommended by PHPs—a cost sometimes exceeding $4,500. If treatment is recommended, the cost may be prohibitive: as high as $39,000 for a "standard" 90-day length of treatment. That's much longer than the 20- to 28-day stay typical for other patients undergoing substance abuse treatment—despite a lack of evidence that health care professionals need longer treatment.

Many centers who provide PHP-recommended evaluations also provide treatment, thus raising the potential for financial incentives for treatment recommendations. Drs Boyd and Knight note that close relationships between treatment centers and state PHPs are "replete with potential conflicts of interest."

The authors also point out problems related to the practice of some PHPs that "any and all" positive test results be reported to the state licensing board—even if they don't indicate substance abuse or relapse. Today's highly sensitive tests can give a positive result even in a person who has used alcohol-based hand sanitizer, as well as some types of asthma inhalers and pain medications. PHPs may instruct doctors to avoid these exposures to simplify interpretation of test results, "rather than what might be in the best interests of the physician."

Use of information about physicians in research by PHPs and their closely intertwined relationships with state licensing boards raise concerns as well. Because most doctors know little about them, PHPs "operate outside the scrutiny of the medical community at large," the authors write. "Physicians referred to PHPs are often compromised to some degree, have very little power, and are therefore not in a position to voice what might be legitimate objections to a PHP's practices."

Drs Boyd and Knight outline recommendations to address the perceived problems. They believe that some form of independent ethical oversight of PHPs should be considered, along with a formal appeals process and a nationwide system for licensing and periodic auditing. They also call on specialty organizations such as the American Society of Addiction Medicine "to review PHP practices and recommend national standards that can be debated by all physicians, not just those who work within PHPs."

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